| NPI | 1669847778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 019258) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA058025) |
| Enumeration Date | 2015-12-01 |
| Last Update Date | 2016-01-04 |