| NPI | 1417506361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 024650) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-008610) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2019-09-04 |
| Last Update Date | 2023-10-06 |