| NPI | 1245357391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 000559) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 000821) |
| Enumeration Date | 2007-03-23 |
| Last Update Date | 2011-04-20 |