| NPI | 1811913700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CT 1485) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001485) |
| Enumeration Date | 2006-07-14 |
| Last Update Date | 2020-04-30 |