| NPI | 1659548634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA066412) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012278) |
| 363A00000X Physician Assistant (Licence: PA OA007192) | |
| Enumeration Date | 2008-05-09 |
| Last Update Date | 2025-03-15 |