| NPI | 1922064468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 016527) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 635) |
| Enumeration Date | 2006-04-25 |
| Last Update Date | 2020-07-06 |