| NPI | 1700154614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 23-015592) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 21962) |
| Enumeration Date | 2011-12-06 |
| Last Update Date | 2021-10-20 |