| NPI | 1821756156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA101140) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 5621) |
| Enumeration Date | 2021-12-03 |
| Last Update Date | 2025-05-14 |