| NPI | 1912434911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 003848) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA6900) |
| Enumeration Date | 2017-05-22 |
| Last Update Date | 2020-06-25 |