| NPI | 1679059281 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 4176) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 027871) |
| 363A00000X Physician Assistant (Licence: CT 4176) | |
| 363AM0700X Physician Assistant, Medical (Licence: CT 4176) | |
| Enumeration Date | 2018-07-17 |
| Last Update Date | 2022-01-25 |