| NPI | 1104252972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 3811) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ME PA1495) |
| Enumeration Date | 2013-09-24 |
| Last Update Date | 2021-12-28 |