| NPI | 1053566174 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA053951) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NY 012540) |
| Enumeration Date | 2008-11-18 |
| Last Update Date | 2014-04-22 |