| NPI | 1689122129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5886) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 019994-1) |
| Enumeration Date | 2016-09-13 |
| Last Update Date | 2023-11-15 |