| NPI | 1962650135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: HI AMD-479) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 23 012731) |
| 363A00000X Physician Assistant (Licence: NH 0983) | |
| Enumeration Date | 2008-08-29 |
| Last Update Date | 2023-01-23 |