NPI | 1104335413 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA2446) |
363A00000X Physician Assistant (Licence: MA PA6317) | |
Enumeration Date | 2017-09-29 |
Last Update Date | 2022-12-02 |