NPI | 1497862205 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 2884) |
Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 000210) |
363A00000X Physician Assistant | |
Enumeration Date | 2006-08-25 |
Last Update Date | 2016-09-02 |