| NPI | 1063453066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NY 0071271) |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2012-03-16 |