| NPI | 1407530116 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 1202761) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085011231) |
| Enumeration Date | 2023-06-13 |
| Last Update Date | 2025-10-25 |