| NPI | 1225897176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 23.006666) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: NY 032316) | |
| 363A00000X Physician Assistant (Licence: MA PA100867) | |
| Enumeration Date | 2024-03-14 |
| Last Update Date | 2024-08-16 |