| NPI | 1053851030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA9201) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020620) |
| Enumeration Date | 2017-02-24 |
| Last Update Date | 2023-11-13 |