| NPI | 1720380017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 002506) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 002506) |
| Enumeration Date | 2010-11-19 |
| Last Update Date | 2016-11-22 |