| NPI | 1073221933 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 7085) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC 4684) |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 7085) | |
| Enumeration Date | 2022-11-09 |
| Last Update Date | 2026-07-17 |