| NPI | 1083675128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 263558-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA-452) |
| Enumeration Date | 2006-03-29 |
| Last Update Date | 2014-10-24 |