| NPI | 1881865533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 011213) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601008481) |
| Enumeration Date | 2008-03-20 |
| Last Update Date | 2017-11-03 |