| NPI | 1871500249 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 002899-1) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110001748) |
| 363AS0400X Physician Assistant, Surgical (Licence: MD C0003447) | |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2015-06-17 |