| NPI | 1740741107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MA PA6996) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: RI PA01296) |
| Enumeration Date | 2019-03-28 |
| Last Update Date | 2024-06-06 |