| NPI | 1649507567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 017803) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA054057) |
| Enumeration Date | 2009-11-13 |
| Last Update Date | 2025-04-23 |