| NPI | 1134439516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 5522) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 014413) |
| Enumeration Date | 2010-10-19 |
| Last Update Date | 2022-08-03 |