| NPI | 1801501770 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 006380) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA9174) |
| Enumeration Date | 2023-01-16 |
| Last Update Date | 2024-02-16 |