| NPI | 1396287819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15930) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020425) |
| Enumeration Date | 2016-11-15 |
| Last Update Date | 2026-03-23 |