| NPI | 1780198804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 021520) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 021520-1) |
| Enumeration Date | 2017-11-28 |
| Last Update Date | 2021-05-13 |