| NPI | 1669913166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 5258) |
| Additional Taxonomies | 222Z00000X Orthotist (Licence: CT CPO03093) |
| 224P00000X Prosthetist (Licence: CT CPO03093) | |
| 363A00000X Physician Assistant | |
| 363AM0700X Physician Assistant Medical (Licence: CT 5258) | |
| Enumeration Date | 2017-03-16 |
| Last Update Date | 2024-02-13 |