| NPI | 1326676156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 4993) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 4993) |
| Enumeration Date | 2020-03-28 |
| Last Update Date | 2021-06-23 |