| NPI | 1962028506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 029292) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 0370759) |
| Enumeration Date | 2020-06-19 |
| Last Update Date | 2025-11-13 |