| NPI | 1952376907 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9107190) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001228) |
| 363A00000X Physician Assistant (Licence: NJ 25mp00085600) | |
| Enumeration Date | 2006-02-22 |
| Last Update Date | 2020-10-01 |