| NPI | 1659801645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 007057) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 025590) |
| Enumeration Date | 2017-06-13 |
| Last Update Date | 2026-04-07 |