| NPI | 1891062055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4590) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 002600) |
| Enumeration Date | 2011-11-16 |
| Last Update Date | 2012-12-28 |