| NPI | 1629218284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 014790) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA054836) |
| Enumeration Date | 2009-02-23 |
| Last Update Date | 2018-03-17 |