| NPI | 1346779154 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA6765) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AM0700X Physician Assistant, Medical (Licence: CT 3890) | |
| Enumeration Date | 2017-06-06 |
| Last Update Date | 2023-05-08 |