| NPI | 1720285380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CT 002550) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011879) |
| 363A00000X Physician Assistant (Licence: CT 002550) | |
| Enumeration Date | 2007-06-28 |
| Last Update Date | 2018-12-24 |