| NPI | 1912729831 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 032029) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 032029) |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 032029) | |
| Enumeration Date | 2024-10-30 |
| Last Update Date | 2024-11-11 |