| NPI | 1093083875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NY 015368) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015368) |
| 363AM0700X Physician Assistant Medical (Licence: NY 015368) | |
| Enumeration Date | 2011-12-07 |
| Last Update Date | 2011-12-08 |