| NPI | 1346214814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 008069) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NY 008069) |
| 363A00000X Physician Assistant (Licence: NY 008069) | |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2024-10-21 |