| NPI | 1972834968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 020729-01) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2010-01-15 |
| Last Update Date | 2023-04-19 |