| NPI | 1306057005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA053499) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 011669) |
| Enumeration Date | 2007-05-24 |
| Last Update Date | 2008-10-03 |