| NPI | 1982954913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CT 2793) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020734) |
| 363A00000X Physician Assistant (Licence: WA PA61060288) | |
| Enumeration Date | 2012-09-18 |
| Last Update Date | 2021-06-16 |