| NPI | 1376196154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: NY 23694) |
| Enumeration Date | 2019-07-19 |
| Last Update Date | 2023-06-30 |