| NPI | 1962493668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 004677) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 004677-1) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2009-09-08 |