| NPI | 1568992030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC 4990) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 020884) |
| Enumeration Date | 2017-06-15 |
| Last Update Date | 2024-06-24 |