| NPI | 1942795620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 022120) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 022120) |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 022120) | |
| Enumeration Date | 2018-06-26 |
| Last Update Date | 2019-12-09 |