| NPI | 1528634185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 27706) |
| Enumeration Date | 2021-06-03 |
| Last Update Date | 2023-07-17 |