| NPI | 1164408712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 022018) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AL PA 370) |
| Enumeration Date | 2005-12-15 |
| Last Update Date | 2018-06-18 |