| NPI | 1164446027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 011208) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 11208) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 011208) | |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2025-08-24 |