| NPI | 1619095106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA ma052963) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 010322-1) |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2018-11-16 |