| NPI | 1942072301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 031831-01) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-10-27 |
| Last Update Date | 2024-06-24 |