| NPI | 1669492054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: 1779) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001779) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2021-06-16 |