| NPI | 1174750806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 3244) |
| Additional Taxonomies | 111NX0800X Chiropractor, Orthopedic (Licence: CT 1799) |
| Enumeration Date | 2009-06-20 |
| Last Update Date | 2015-06-01 |