| NPI | 1487614160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: CT NO LICENSES YET) |
| 363A00000X Physician Assistant (Licence: CT 002645) | |
| Enumeration Date | 2006-03-25 |
| Last Update Date | 2018-05-23 |