| NPI | 1194030569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CT 3056) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: CT 001849) |
| Enumeration Date | 2010-08-10 |
| Last Update Date | 2014-02-27 |