| NPI | 1922350073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 016116) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08374) |
| Enumeration Date | 2012-10-12 |
| Last Update Date | 2025-10-09 |