| NPI | 1770603755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 006260) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2007-03-31 |
| Last Update Date | 2025-09-12 |