| NPI | 1366175754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8901) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 028796) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2022-07-05 |
| Last Update Date | 2025-12-15 |