| NPI | 1104868942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 6417) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 006882) |
| Enumeration Date | 2006-06-12 |
| Last Update Date | 2024-04-01 |