| NPI | 1619918323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CT CT001357) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001357) |
| Enumeration Date | 2006-06-10 |
| Last Update Date | 2022-01-31 |