| NPI | 1972149144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 23.004803) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0006001) |
| 363A00000X Physician Assistant (Licence: IL 085007460) | |
| Enumeration Date | 2019-11-22 |
| Last Update Date | 2020-05-04 |