| NPI | 1881073997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MD C0005754) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 018510) |
| Enumeration Date | 2015-05-21 |
| Last Update Date | 2019-10-16 |