| NPI | 1023597028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: CT 4280) |
| Enumeration Date | 2018-08-09 |
| Last Update Date | 2022-04-05 |