| NPI | 1356867808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 021163) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 6626) |
| Enumeration Date | 2017-08-16 |
| Last Update Date | 2025-08-22 |