| NPI | 1538317144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 012742) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 3348) |
| Enumeration Date | 2008-09-08 |
| Last Update Date | 2022-04-15 |