| NPI | 1346503612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 002753) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 2753) |
| Enumeration Date | 2012-06-20 |
| Last Update Date | 2018-09-27 |