| NPI | 1164458204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 001642) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 001642) |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 009283) | |
| Enumeration Date | 2006-06-23 |
| Last Update Date | 2022-10-03 |