| NPI | 1699381616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 003824-1) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 003824-1) |
| Enumeration Date | 2020-09-16 |
| Last Update Date | 2021-04-30 |