NPI | 1053650929 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 016372-1) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 016372-1) |
Enumeration Date | 2013-02-12 |
Last Update Date | 2025-09-10 |