| NPI | 1427486380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 3015) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9120352) |
| Enumeration Date | 2013-10-30 |
| Last Update Date | 2025-10-28 |