| NPI | 1205964426 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 001888) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001888) |
| Enumeration Date | 2007-03-01 |
| Last Update Date | 2023-12-08 |