| NPI | 1548801830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 4646) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 4646) |
| Enumeration Date | 2019-10-08 |
| Last Update Date | 2025-09-15 |