| NPI | 1164622494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 011629) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 3643) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9113858) | |
| Enumeration Date | 2007-07-24 |
| Last Update Date | 2021-11-15 |