| NPI | 1720274053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NH 0676) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY P61030) |
| Enumeration Date | 2007-09-20 |
| Last Update Date | 2017-02-27 |