| NPI | 1710995204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 000270) |
| Additional Taxonomies | 174400000X Specialist (Licence: CT 000270) |
| 363A00000X Physician Assistant (Licence: CT 000270) | |
| Enumeration Date | 2006-08-03 |
| Last Update Date | 2014-08-08 |