| NPI | 1578613964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 2235) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 18730) |
| 363AM0700X Physician Assistant, Medical (Licence: MA PA4176) | |
| Enumeration Date | 2007-01-10 |
| Last Update Date | 2016-06-07 |