| NPI | 1457099335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA9173) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical (Licence: CT 5718) | |
| Enumeration Date | 2022-05-22 |
| Last Update Date | 2023-05-03 |