| NPI | 1912404401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9381) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 021986) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 021986) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 021986) | |
| Enumeration Date | 2018-04-10 |
| Last Update Date | 2024-08-07 |