| NPI | 1518943810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 001195) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 789) |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2012-01-10 |