| NPI | 1336144856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 6103) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: RI PA00317) |
| Enumeration Date | 2005-06-21 |
| Last Update Date | 2023-07-07 |