| NPI | 1306216288 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA057931) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 22861) |
| Enumeration Date | 2015-10-05 |
| Last Update Date | 2023-07-03 |