| NPI | 1669848289 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 029282-01) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 7769) |
| 363A00000X Physician Assistant (Licence: CA PA68499) | |
| Enumeration Date | 2015-08-18 |
| Last Update Date | 2026-07-17 |