| NPI | 1003370719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 5091) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 023192) |
| Enumeration Date | 2019-01-27 |
| Last Update Date | 2022-12-28 |