| NPI | 1427337385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 2785) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA4219) |
| Enumeration Date | 2011-08-10 |
| Last Update Date | 2019-09-10 |