| NPI | 1972979953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 018922) |
| Additional Taxonomies | 282N00000X General Acute Care Hospital (Licence: NY 018922) |
| Enumeration Date | 2015-08-13 |
| Last Update Date | 2018-06-06 |