| NPI | 1194198168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 003464) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 003464) |
| 363A00000X Physician Assistant (Licence: NY 019183-1) | |
| Enumeration Date | 2015-11-12 |
| Last Update Date | 2016-02-26 |