| NPI | 1811240484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 021685) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: NY 310238-1) |
| Enumeration Date | 2012-10-19 |
| Last Update Date | 2017-12-12 |