| NPI | 1013483049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA065477) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 022796) |
| Enumeration Date | 2018-10-17 |
| Last Update Date | 2026-02-20 |