| NPI | 1255679882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 016247) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NY 16247) |
| Enumeration Date | 2013-01-16 |
| Last Update Date | 2023-07-07 |