| NPI | 1750799318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 017758) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 4717) |
| Enumeration Date | 2014-07-28 |
| Last Update Date | 2020-01-28 |