| NPI | 1154963387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA065622) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 026835) |
| Enumeration Date | 2019-10-09 |
| Last Update Date | 2026-05-18 |