| NPI | 1790838399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 016288) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PAL2348) |
| Enumeration Date | 2007-01-19 |
| Last Update Date | 2019-06-26 |