| NPI | 1831555747 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 019415) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NY 019415) |
| 363AS0400X Physician Assistant Surgical (Licence: NY 019415) | |
| Enumeration Date | 2016-01-07 |
| Last Update Date | 2016-01-07 |