| NPI | 1457661373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 23-006995) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 23-006995) |
| Enumeration Date | 2010-10-13 |
| Last Update Date | 2020-04-07 |