| NPI | 1669636460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 012796) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-03610) |
| Enumeration Date | 2008-07-11 |
| Last Update Date | 2024-08-23 |