| NPI | 1114992666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 211) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 000211) |
| Enumeration Date | 2006-02-20 |
| Last Update Date | 2018-08-21 |