| NPI | 1508026105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NY 012601) |
| Enumeration Date | 2008-06-17 |
| Last Update Date | 2019-09-18 |