| NPI | 1134445760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 003256) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 013878) |
| Enumeration Date | 2010-04-07 |
| Last Update Date | 2015-02-12 |