| NPI | 1265869648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: NY 342581) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363A00000X Physician Assistant (Licence: NY 017009) | |
| Enumeration Date | 2013-10-01 |
| Last Update Date | 2026-09-11 |