| NPI | 1548842610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 5287) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 23.005287) |
| Enumeration Date | 2021-04-27 |
| Last Update Date | 2022-10-13 |