| NPI | 1962649194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 014603-4) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA052472) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA052472) | |
| Enumeration Date | 2009-01-09 |
| Last Update Date | 2015-12-14 |