| NPI | 1356522031 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 012239) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 012239) |
| Enumeration Date | 2007-11-21 |
| Last Update Date | 2025-04-04 |