| NPI | 1639295355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9113489) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 0025031) |
| Enumeration Date | 2007-03-22 |
| Last Update Date | 2022-03-11 |