| NPI | 1720463177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5457) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 018849-1) |
| Enumeration Date | 2015-07-28 |
| Last Update Date | 2015-07-28 |