| NPI | 1417215393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 003738) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 1101806) |
| Enumeration Date | 2012-04-27 |
| Last Update Date | 2017-02-07 |