| NPI | 1972965382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA5636) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NH 1157) |
| Enumeration Date | 2016-03-24 |
| Last Update Date | 2016-03-24 |