| NPI | 1083632160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA059673) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA059673) |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 004445) | |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2019-01-18 |