| NPI | 1003207929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5226) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: MA E881169) |
| Enumeration Date | 2015-02-13 |
| Last Update Date | 2015-02-13 |