| 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 |