| NPI | 1952328759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-09327) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 001121) |
| Enumeration Date | 2006-07-16 |
| Last Update Date | 2021-12-07 |