| NPI | 1710339908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT CT0641) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9109524) |
| Enumeration Date | 2016-07-12 |
| Last Update Date | 2025-07-22 |