| NPI | 1659927929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 6689) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 023849) |
| Enumeration Date | 2019-08-13 |
| Last Update Date | 2024-11-18 |