| NPI | 1922033125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 290) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2019-04-26 |