| NPI | 1689852410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 23.002924) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00159800) |
| 363A00000X Physician Assistant (Licence: MD C0003922) | |
| 363AM0700X Physician Assistant, Medical (Licence: CA PA18705) | |
| 363AM0700X Physician Assistant, Medical (Licence: MO 2012007333) | |
| Enumeration Date | 2008-02-04 |
| Last Update Date | 2017-01-13 |