| NPI | 1346931839 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 030605) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| 363AS0400X Physician Assistant Surgical | |
| Enumeration Date | 2023-05-16 |
| Last Update Date | 2023-10-23 |