| NPI | 1568891729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 5706) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA23254) |
| Enumeration Date | 2013-11-07 |
| Last Update Date | 2022-07-11 |