| NPI | 1386045367 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 4049) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1045) |
| Enumeration Date | 2014-09-10 |
| Last Update Date | 2024-10-24 |