| NPI | 1679348205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA006887) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 031202) |
| 363A00000X Physician Assistant (Licence: PA MA065666) | |
| Enumeration Date | 2023-11-27 |
| Last Update Date | 2024-07-03 |