| NPI | 1972691806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 012559) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA002486L) |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2021-03-31 |