| NPI | 1679125215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114903) |
| Additional Taxonomies | 2084N0400X Psychiatry & Neurology, Neurology (Licence: NY 025724) |
| Enumeration Date | 2019-07-14 |
| Last Update Date | 2023-07-10 |