| NPI | 1952315632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 51497) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MT196278) |
| 363A00000X Physician Assistant (Licence: CT 001400) | |
| 363AM0700X Physician Assistant, Medical (Licence: CT 001400) | |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA053911) | |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2022-12-09 |