| NPI | 1679556856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CT 000680) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 000680) |
| Enumeration Date | 2005-11-22 |
| Last Update Date | 2017-05-02 |