| NPI | 1457589921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL 9111483) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 004301) |
| Enumeration Date | 2009-06-23 |
| Last Update Date | 2021-05-06 |