| NPI | 1235294596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 001723) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 005201) |
| Enumeration Date | 2006-12-27 |
| Last Update Date | 2010-09-16 |