| NPI | 1326297458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 5242) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-04191) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA053589) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-04191) | |
| Enumeration Date | 2008-09-12 |
| Last Update Date | 2022-02-09 |