| NPI | 1194177972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VT 055.0031539) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA6015) |
| 363A00000X Physician Assistant (Licence: ME PA2330) | |
| 363A00000X Physician Assistant | |
| 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00483300) | |
| Enumeration Date | 2016-07-06 |
| Last Update Date | 2025-01-28 |