| NPI | 1093062960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 0911) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA4460) |
| 363AS0400X Physician Assistant, Surgical (Licence: MA PA4460) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NH 0911) | |
| Enumeration Date | 2012-08-10 |
| Last Update Date | 2024-06-18 |