| NPI | 1972935385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0008649) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VT 055.0031177) |
| Enumeration Date | 2013-08-07 |
| Last Update Date | 2024-11-13 |