| NPI | 1669109963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA065466) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 1190047) |
| Enumeration Date | 2022-08-05 |
| Last Update Date | 2024-06-19 |