| NPI | 1194249136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8684) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: CT 3945) | |
| Enumeration Date | 2017-08-01 |
| Last Update Date | 2022-04-21 |