| NPI | 1972119600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8749) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 027584) |
| Enumeration Date | 2020-09-18 |
| Last Update Date | 2022-10-11 |