| NPI | 1548632581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 3466) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA101950) |
| Enumeration Date | 2015-10-29 |
| Last Update Date | 2025-10-09 |