| NPI | 1619356037 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 4228) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1103) |
| Enumeration Date | 2015-05-19 |
| Last Update Date | 2019-12-02 |