| NPI | 1629086962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ME 001186) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 001431) |
| Enumeration Date | 2006-08-03 |
| Last Update Date | 2009-10-08 |