| NPI | 1184145906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 3915) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-07-01 |
| Last Update Date | 2022-08-05 |