| NPI | 1255589107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112104) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 23012692) |
| Enumeration Date | 2008-09-04 |
| Last Update Date | 2023-01-24 |