| NPI | 1083158455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1361) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5940) |
| Enumeration Date | 2016-12-05 |
| Last Update Date | 2018-07-26 |