| NPI | 1548566847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014585) |
| Enumeration Date | 2011-02-03 |
| Last Update Date | 2021-12-06 |