| NPI | 1659820835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4258) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020218) |
| Enumeration Date | 2016-09-28 |
| Last Update Date | 2023-12-21 |