| NPI | 1689655300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 001000) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA PA19752) |
| Enumeration Date | 2005-11-09 |
| Last Update Date | 2013-04-09 |