| NPI | 1023698255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 026081) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005309) |
| 363A00000X Physician Assistant (Licence: PA MA061741) | |
| Enumeration Date | 2021-04-12 |
| Last Update Date | 2022-03-04 |