| NPI | 1114411766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 4164) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: CT 1164) | |
| Enumeration Date | 2018-06-18 |
| Last Update Date | 2020-04-27 |