| NPI | 1104356377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NY 024491) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 024491) |
| 363AM0700X Physician Assistant Medical (Licence: PA MA059231) | |
| Enumeration Date | 2017-06-19 |
| Last Update Date | 2024-03-07 |