| NPI | 1972796696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 012686-1) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012686) |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 002057) | |
| Enumeration Date | 2007-08-27 |
| Last Update Date | 2022-06-06 |