| NPI | 1700859006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 001890) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 104122) |
| 363A00000X Physician Assistant (Licence: NY 004547-1) | |
| 363AM0700X Physician Assistant Medical (Licence: CT 001890) | |
| Enumeration Date | 2006-02-08 |
| Last Update Date | 2022-05-27 |