| NPI | 1679934988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 5082) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 53272) |
| Enumeration Date | 2016-03-14 |
| Last Update Date | 2021-04-08 |