| NPI | 1215265582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA1253) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: RI PA00513) |
| Enumeration Date | 2009-11-25 |
| Last Update Date | 2024-01-25 |