| NPI | 1396727533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CT 001706) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001706) |
| Enumeration Date | 2005-11-15 |
| Last Update Date | 2021-12-06 |