| 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 |