| NPI | 1760715213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 020817) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA0504084) |
| Enumeration Date | 2009-09-16 |
| Last Update Date | 2018-03-27 |