| NPI | 1881161107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA9458) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 023205-1) |
| Enumeration Date | 2018-10-24 |
| Last Update Date | 2023-12-26 |