| NPI | 1790938520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 012924-1) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 2972) |
| Enumeration Date | 2008-10-24 |
| Last Update Date | 2025-03-31 |