| NPI | 1861944084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 003759) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020255-1) |
| Enumeration Date | 2016-11-04 |
| Last Update Date | 2021-03-29 |