| NPI | 1740320092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 017907) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA000913) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 003346) | |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2022-11-15 |