| NPI | 1851569081 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 344865) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 009670) |
| Enumeration Date | 2008-02-11 |
| Last Update Date | 2025-04-23 |