| NPI | 1861406597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 5858) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 510) |
| 363A00000X Physician Assistant (Licence: MA PA510) | |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2026-05-15 |