| NPI | 1710125190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6524) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 002219) |
| Enumeration Date | 2009-01-23 |
| Last Update Date | 2019-04-11 |