| NPI | 1972676229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 006371-01) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 2295) |
| Enumeration Date | 2006-11-16 |
| Last Update Date | 2025-11-03 |