| NPI | 1831509702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA4988) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 3093) |
| Enumeration Date | 2014-05-01 |
| Last Update Date | 2016-10-26 |