| NPI | 1619195831 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 008549) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: 5601013004) |
| Enumeration Date | 2007-04-23 |
| Last Update Date | 2025-05-20 |