| NPI | 1992108674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CT 3214) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: CT 3214) |
| 363A00000X Physician Assistant (Licence: CT 3214) | |
| Enumeration Date | 2014-10-08 |
| Last Update Date | 2020-10-12 |