| NPI | 1952495517 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4504) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 003476) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2022-12-28 |