| NPI | 1568815009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 6295) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3841-23) |
| 363A00000X Physician Assistant (Licence: NH 1621) | |
| Enumeration Date | 2016-07-20 |
| Last Update Date | 2023-11-21 |