| NPI | 1902113384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 002863) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014228) |
| 363A00000X Physician Assistant (Licence: CT 002863) | |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 002863) | |
| Enumeration Date | 2010-09-08 |
| Last Update Date | 2019-01-04 |