| NPI | 1700817061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 000720) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 006244) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2012-02-24 |