| NPI | 1851955256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA7645) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 7016) |
| Enumeration Date | 2019-05-01 |
| Last Update Date | 2025-07-03 |