| NPI | 1962948539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C06779) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C06779) |
| 363A00000X Physician Assistant (Licence: NY 020509) | |
| Enumeration Date | 2017-01-06 |
| Last Update Date | 2019-08-30 |