| NPI | 1023715638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 033035) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA9324) |
| Enumeration Date | 2023-02-14 |
| Last Update Date | 2025-03-15 |