| NPI | 1396186631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 003328) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA056193) |
| Enumeration Date | 2013-07-16 |
| Last Update Date | 2015-10-15 |