| NPI | 1174939425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 017678) |
| Additional Taxonomies | 208VP0000X (Licence: NY 017678) |
| Enumeration Date | 2014-07-08 |
| Last Update Date | 2026-03-18 |