| NPI | 1295723609 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 1956) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 000528) |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2007-07-08 |