| NPI | 1003546094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA063602) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 029929) |
| 363A00000X Physician Assistant (Licence: PA MA063602) | |
| Enumeration Date | 2022-06-13 |
| Last Update Date | 2025-07-21 |