| NPI | 1083012769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 23018295) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 018295) |
| Enumeration Date | 2014-12-12 |
| Last Update Date | 2025-09-22 |