| NPI | 1114476132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 23.003703) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 9218) |
| Enumeration Date | 2016-10-03 |
| Last Update Date | 2022-09-12 |