| NPI | 1679037980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 023325-01) |
| Enumeration Date | 2019-01-31 |
| Last Update Date | 2019-08-01 |