| NPI | 1730050394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 23.007322) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 23.007322) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 23.007322) | |
| Enumeration Date | 2025-09-16 |
| Last Update Date | 2025-10-17 |