| NPI | 1639166911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 000991) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 000991) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 000991) | |
| Enumeration Date | 2005-10-03 |
| Last Update Date | 2014-05-27 |