| NPI | 1649839598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 032372) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601009217) |
| Enumeration Date | 2019-06-12 |
| Last Update Date | 2025-07-20 |