| NPI | 1740254804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 001930) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 007893) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2013-01-03 |