| NPI | 1063885713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 019403) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: HI AMD828) |
| Enumeration Date | 2015-11-03 |
| Last Update Date | 2023-06-15 |