| NPI | 1912209347 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 014323) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014323) |
| Enumeration Date | 2010-11-17 |
| Last Update Date | 2019-05-17 |