| NPI | 1366201808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 031597) |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 031597) | |
| Enumeration Date | 2024-03-18 |
| Last Update Date | 2024-03-19 |