| NPI | 1891510806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 7045) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-11-15 |
| Last Update Date | 2025-07-14 |