| NPI | 1811285455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 014876-1) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014876) |
| Enumeration Date | 2011-07-18 |
| Last Update Date | 2012-11-09 |