| NPI | 1477126464 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 026831) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 026831) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 26831) | |
| Enumeration Date | 2021-07-19 |
| Last Update Date | 2025-01-15 |