| NPI | 1184141210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 4010) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA100028) |
| Enumeration Date | 2017-08-29 |
| Last Update Date | 2024-06-07 |