| NPI | 1124595889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 5109) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 022781) |
| Enumeration Date | 2018-10-30 |
| Last Update Date | 2025-11-10 |