| NPI | 1285189845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5893) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 23.003656) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 003656) | |
| Enumeration Date | 2016-08-23 |
| Last Update Date | 2026-07-06 |