| NPI | 1205067220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 002579) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA4019) |
| Enumeration Date | 2009-08-07 |
| Last Update Date | 2011-08-31 |