| NPI | 1770888125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 4249) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012411) |
| Enumeration Date | 2011-01-17 |
| Last Update Date | 2022-01-26 |