| NPI | 1518463678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CT 004136) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 004136) |
| 363AM0700X Physician Assistant Medical (Licence: CT 004136) | |
| Enumeration Date | 2018-04-05 |
| Last Update Date | 2018-09-10 |