| 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 |