| NPI | 1023844412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9119132) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 034491) |
| Enumeration Date | 2024-09-11 |
| Last Update Date | 2026-07-09 |