| NPI | 1790751675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA052165) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 000760-1) |
| Enumeration Date | 2006-02-28 |
| Last Update Date | 2021-03-01 |