| NPI | 1669841920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NY 019038) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 019038-1) |
| Enumeration Date | 2015-09-16 |
| Last Update Date | 2019-10-04 |