| NPI | 1669400206 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 001238) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 0012381) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2011-02-11 |