| NPI | 1396488268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 1830553) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 5634) |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 5634) | |
| Enumeration Date | 2022-04-18 |
| Last Update Date | 2026-01-25 |