| NPI | 1891297727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA7103) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical (Licence: CT 23.004076) | |
| Enumeration Date | 2018-03-07 |
| Last Update Date | 2020-03-25 |