| NPI | 1588074884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 004812) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 51500) |
| Enumeration Date | 2014-05-07 |
| Last Update Date | 2020-07-20 |