| NPI | 1811515208 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 6355) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 8174) |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 6355) | |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 8174) | |
| Enumeration Date | 2020-07-11 |
| Last Update Date | 2024-02-28 |