| NPI | 1740606359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA056764) |
| Additional Taxonomies | 103TP0016X Psychologist, Prescribing (Medical) (Licence: NY 122219) |
| Enumeration Date | 2014-03-07 |
| Last Update Date | 2023-07-14 |