| NPI | 1063833069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 026169-01) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-04670) |
| Enumeration Date | 2013-12-18 |
| Last Update Date | 2023-04-28 |