| NPI | 1619918968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110006808) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 006239) |
| 363A00000X Physician Assistant (Licence: NY 006239) | |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2023-06-22 |