| NPI | 1659601490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251V00000X Voluntary or Charitable (Licence: NY 002154) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 002154) |
| Enumeration Date | 2009-12-29 |
| Last Update Date | 2009-12-29 |