| NPI | 1629224126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA2565) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 3648) |
| Enumeration Date | 2008-08-15 |
| Last Update Date | 2016-09-09 |