| NPI | 1033894969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 23.006230) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-06-19 |
| Last Update Date | 2023-08-11 |