| NPI | 1457660466 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 02871301) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 1095084) |
| Enumeration Date | 2010-09-26 |
| Last Update Date | 2026-08-17 |