| NPI | 1669599882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 008762) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 001653) |
| Enumeration Date | 2007-03-23 |
| Last Update Date | 2021-03-12 |