| NPI | 1154718518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 3311) |
| Enumeration Date | 2015-04-22 |
| Last Update Date | 2023-10-06 |