| NPI | 1790129542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 016542) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 1110030) |
| Enumeration Date | 2013-04-23 |
| Last Update Date | 2020-10-05 |