| NPI | 1730676081 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 031770) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08200) |
| Enumeration Date | 2018-04-21 |
| Last Update Date | 2025-05-07 |