| NPI | 1124132089 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 001264) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 1264) |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2019-10-11 |