| NPI | 1629720644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 028216) |
| Enumeration Date | 2022-01-20 |
| Last Update Date | 2024-09-30 |