| NPI | 1790459816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 2745644) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00760900) | |
| Enumeration Date | 2021-08-03 |
| Last Update Date | 2026-08-05 |