| NPI | 1538281670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5787) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001639) |
| Enumeration Date | 2007-04-06 |
| Last Update Date | 2018-12-20 |