| NPI | 1952778276 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 6097) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2825) |
| 363AM0700X Physician Assistant Medical (Licence: TN 2825) | |
| Enumeration Date | 2015-08-24 |
| Last Update Date | 2023-07-25 |