| NPI | 1598112047 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 026980-01) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2016-05-14 |
| Last Update Date | 2021-11-20 |