| NPI | 1235723388 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NY 026659) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-03-01 |
| Last Update Date | 2021-08-11 |