| NPI | 1962587667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA 1902) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 2213) |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2015-08-06 |