| NPI | 1780952242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 002734) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1100498) |
| Enumeration Date | 2011-12-12 |
| Last Update Date | 2012-11-20 |