| NPI | 1184134702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 005947) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 021428) |
| Enumeration Date | 2017-10-10 |
| Last Update Date | 2023-03-15 |