| NPI | 1619933389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CT 749) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 000749) |
| Enumeration Date | 2006-04-21 |
| Last Update Date | 2021-01-10 |