| NPI | 1760035547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 4519) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 4519) |
| 363A00000X Physician Assistant (Licence: MA PA9418) | |
| Enumeration Date | 2019-07-20 |
| Last Update Date | 2024-11-21 |