| NPI | 1790903862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 004010) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 004010) |
| Enumeration Date | 2007-04-23 |
| Last Update Date | 2019-12-16 |