| NPI | 1770067605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA8261) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 022567) |
| Enumeration Date | 2018-09-17 |
| Last Update Date | 2022-09-08 |