NPI | 1760035547 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 4519) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA9418) |
363AM0700X Physician Assistant, Medical (Licence: CT 4519) | |
363AM0700X Physician Assistant, Medical (Licence: MA PA9418) | |
Enumeration Date | 2019-07-20 |
Last Update Date | 2025-08-28 |