| NPI | 1700096583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007831) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 007239) |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2025-12-16 |