| NPI | 1487120077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 028090) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 7577) |
| Enumeration Date | 2018-10-22 |
| Last Update Date | 2023-03-21 |