| NPI | 1699451914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 034069) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA064582) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 034069) | |
| Enumeration Date | 2023-06-22 |
| Last Update Date | 2025-09-23 |