| NPI | 1245749936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA063375) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 3959) |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 3959) | |
| Enumeration Date | 2017-09-25 |
| Last Update Date | 2022-06-14 |