| NPI | 1902270515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA6416) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 003465) |
| Enumeration Date | 2015-11-19 |
| Last Update Date | 2023-02-15 |