| NPI | 1740326651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 2555) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011449-1) |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2013-01-24 |