| NPI | 1366245128 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 7037) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 7037) |
| Enumeration Date | 2025-03-28 |
| Last Update Date | 2025-04-09 |