| NPI | 1790222123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 020512) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-14008) |
| Enumeration Date | 2017-01-24 |
| Last Update Date | 2024-03-14 |