| NPI | 1962707455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 014557) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: LA PA.200804.RX) |
| Enumeration Date | 2011-01-14 |
| Last Update Date | 2022-08-10 |