| NPI | 1255366795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 000911) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 008705) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2026-02-19 |