| NPI | 1629616768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 5977) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 027289) |
| Enumeration Date | 2019-12-19 |
| Last Update Date | 2025-08-20 |