| NPI | 1518248954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CT 2933) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1680) |
| Enumeration Date | 2011-08-30 |
| Last Update Date | 2013-07-10 |