| NPI | 1366596553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 004101) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 008002) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2023-01-26 |