| NPI | 1629554860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 022219) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 22219) |
| Enumeration Date | 2018-07-11 |
| Last Update Date | 2025-07-11 |