| NPI | 1073029146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 029754) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 8686) |
| Enumeration Date | 2017-12-27 |
| Last Update Date | 2023-05-09 |