| NPI | 1023239555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 12637) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012637) |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 001904) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 012637) | |
| Enumeration Date | 2007-05-01 |
| Last Update Date | 2019-09-11 |