| NPI | 1023096237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 001247) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA11519) |
| Enumeration Date | 2006-01-06 |
| Last Update Date | 2025-01-22 |