NPI | 1003005174 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057342) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA2170) |
363A00000X Physician Assistant (Licence: MA 2386) | |
Enumeration Date | 2007-10-15 |
Last Update Date | 2021-06-02 |