| NPI | 1457902066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 028159) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061113) |
| Enumeration Date | 2019-09-25 |
| Last Update Date | 2023-09-13 |