| NPI | 1639166192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 003695) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 3695) |
| Enumeration Date | 2005-09-30 |
| Last Update Date | 2023-06-29 |