| NPI | 1811379472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 026561) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1650) |
| Enumeration Date | 2015-06-19 |
| Last Update Date | 2021-12-01 |