| NPI | 1932867553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA101453) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 027814) |
| Enumeration Date | 2021-12-01 |
| Last Update Date | 2025-04-15 |