| NPI | 1033218011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 002268) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MA 1420) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2011-02-23 |