| NPI | 1922340181 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 002888) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 002888) |
| 363L00000X Nurse Practitioner (Licence: CT 002888) | |
| Enumeration Date | 2013-03-25 |
| Last Update Date | 2013-05-09 |