| NPI | 1275189797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0007700) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 026310) |
| Enumeration Date | 2019-08-12 |
| Last Update Date | 2023-11-30 |