| NPI | 1750106340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 033388) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.009058RX) |
| Enumeration Date | 2024-11-19 |
| Last Update Date | 2025-06-06 |