| NPI | 1639251366 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 012121-1) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110001169) |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2008-02-13 |