| NPI | 1790467967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 030840) |
| Enumeration Date | 2023-08-07 |
| Last Update Date | 2024-04-30 |