| NPI | 1205291754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 023483) |
| Enumeration Date | 2015-12-29 |
| Last Update Date | 2025-03-31 |