| NPI | 1104067776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 013161) |
| Enumeration Date | 2009-03-11 |
| Last Update Date | 2022-11-23 |