| NPI | 1619500063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 024822) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 1171311) |
| Enumeration Date | 2020-02-13 |
| Last Update Date | 2021-10-01 |