| NPI | 1942405246 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JODIE JACOBY Office Manager 860-673-1667 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: CT 016756) |
| Additional Taxonomies | 174400000X Specialist (Licence: CT 022522) |
| 363A00000X Physician Assistant (Licence: CT 000178) | |
| Enumeration Date | 2007-06-18 |
| Last Update Date | 2020-08-22 |