| NPI | 1013018969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 002782) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 009834) |
| 363A00000X Physician Assistant (Licence: FL PA9103146) | |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2012-11-28 |