| NPI | 1770166134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA9305) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 5306) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 5306) | |
| Enumeration Date | 2021-05-04 |
| Last Update Date | 2023-05-22 |