| NPI | 1760100788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 5869) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2022-08-16 |
| Last Update Date | 2022-11-02 |