| NPI | 1447308457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: FL 9106591) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NY 009749-1) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2020-05-19 |