| NPI | 1760452411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 010004) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA052116) |
| Enumeration Date | 2006-01-25 |
| Last Update Date | 2015-06-29 |