| NPI | 1518074210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NY 0095811) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 009581) |
| Enumeration Date | 2006-08-25 |
| Last Update Date | 2021-05-21 |