| NPI | 1336476159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN 1533) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 451) |
| Enumeration Date | 2009-11-16 |
| Last Update Date | 2015-04-30 |