| NPI | 1043811201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 7250) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 60480) |
| Enumeration Date | 2020-11-04 |
| Last Update Date | 2025-12-17 |