| NPI | 1992272033 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061922) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 025316) |
| Enumeration Date | 2018-10-26 |
| Last Update Date | 2020-10-19 |