| NPI | 1942080684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 031944) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 031944) |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 031944) | |
| Enumeration Date | 2023-10-02 |
| Last Update Date | 2024-11-01 |