| NPI | 1760025761 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 024443) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 00000) |
| Enumeration Date | 2019-10-22 |
| Last Update Date | 2019-11-21 |