| NPI | 1104466077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 024542-01) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 24542) |
| Enumeration Date | 2020-01-08 |
| Last Update Date | 2023-07-03 |