| NPI | 1619975612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 000248) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 000248) |
| Enumeration Date | 2005-07-13 |
| Last Update Date | 2012-03-07 |