| NPI | 1609434000 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 027880) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1502260) |
| Enumeration Date | 2019-05-31 |
| Last Update Date | 2022-06-15 |