| NPI | 1124461371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4608) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 002867) |
| Enumeration Date | 2013-04-08 |
| Last Update Date | 2024-10-09 |