| NPI | 1275817934 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 1102319) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110-004585) |
| 363AS0400X Physician Assistant, Surgical (Licence: MD C0004795) | |
| Enumeration Date | 2011-09-29 |
| Last Update Date | 2015-01-30 |