| NPI | 1013938356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 1476) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 5060) |
| Enumeration Date | 2006-07-22 |
| Last Update Date | 2023-11-17 |