| NPI | 1417160839 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 09104-1) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CA PA57835) |
| 363AS0400X Physician Assistant, Surgical (Licence: RI PA 00378) | |
| Enumeration Date | 2007-05-08 |
| Last Update Date | 2024-07-05 |