| NPI | 1760486724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2469) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 006171-0) |
| Enumeration Date | 2005-06-08 |
| Last Update Date | 2021-02-01 |