| NPI | 1225163488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 2824) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 0149) |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2022-05-04 |