| NPI | 1104202241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 3336) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 3336) |
| Enumeration Date | 2015-07-30 |
| Last Update Date | 2015-10-30 |