| NPI | 1558678433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 2474) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 015493) |
| 363AM0700X Physician Assistant, Medical (Licence: MA PA8052) | |
| Enumeration Date | 2010-09-13 |
| Last Update Date | 2025-04-09 |