| NPI | 1639107196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NY 006921) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 006921) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2021-12-22 |