| NPI | 1255067104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 5822) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2022-07-25 |
| Last Update Date | 2022-12-09 |