| NPI | 1770951873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 0109006) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 0109006) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 019006) | |
| Enumeration Date | 2015-09-04 |
| Last Update Date | 2023-02-01 |