| NPI | 1619400157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 020752-1) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0009253) |
| 363A00000X Physician Assistant (Licence: DE C5-0012025) | |
| Enumeration Date | 2017-04-11 |
| Last Update Date | 2024-07-22 |