| NPI | 1760025985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 026463) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0007368) |
| Enumeration Date | 2019-10-21 |
| Last Update Date | 2021-04-27 |