| NPI | 1679556385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA2208) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 000722) |
| Enumeration Date | 2005-11-28 |
| Last Update Date | 2026-05-15 |