| NPI | 1356729768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5568) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 3318) |
| Enumeration Date | 2015-05-18 |
| Last Update Date | 2022-03-22 |