| NPI | 1205501822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1802) |
| 363AS0400X Physician Assistant, Surgical (Licence: NH 1802) | |
| Enumeration Date | 2021-08-16 |
| Last Update Date | 2023-10-12 |