| NPI | 1710547294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 4556) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-06-17 |
| Last Update Date | 2026-04-19 |