| NPI | 1760922454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VT 055.0031409) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA6052) |
| Enumeration Date | 2017-03-01 |
| Last Update Date | 2018-12-19 |