| NPI | 1114194669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9111306) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 012516) |
| Enumeration Date | 2008-05-14 |
| Last Update Date | 2019-08-09 |