| NPI | 1922232321 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 002512) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA ma051588) |
| Enumeration Date | 2009-05-13 |
| Last Update Date | 2011-04-19 |