| NPI | 1861152589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 027653-01) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA062858) |
| 363A00000X Physician Assistant (Licence: PA OA005933) | |
| Enumeration Date | 2021-12-21 |
| Last Update Date | 2021-12-21 |