| NPI | 1619040391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CT 002987) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 002987) |
| 363AM0700X Physician Assistant Medical (Licence: MD C0003439) | |
| 363AS0400X Physician Assistant Surgical (Licence: CT 002987) | |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2013-12-20 |