| NPI | 1609292234 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 7570) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 51450) |
| Enumeration Date | 2014-03-06 |
| Last Update Date | 2026-03-17 |