| NPI | 1093417768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 6117) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CT 6117) |
| Enumeration Date | 2023-03-20 |
| Last Update Date | 2025-02-20 |