| NPI | 1467061648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 4925) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-07-23 |
| Last Update Date | 2023-03-31 |