| NPI | 1972024594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8960) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020926) |
| Enumeration Date | 2017-07-05 |
| Last Update Date | 2023-01-26 |