| NPI | 1790870301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA 2143) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 001782) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2022-06-21 |