| NPI | 1518182104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CT 3403) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MA PA6192) |
| Enumeration Date | 2007-04-17 |
| Last Update Date | 2023-02-15 |