| NPI | 1003499427 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 23.005251) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50.009800RX) |
| Enumeration Date | 2021-05-03 |
| Last Update Date | 2026-01-21 |