| NPI | 1508517897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 032617) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA9474) |
| 363A00000X Physician Assistant (Licence: NH 2127) | |
| Enumeration Date | 2022-01-18 |
| Last Update Date | 2025-02-12 |