| NPI | 1073697108 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 001721) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001721) |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2012-01-12 |