| NPI | 1104335413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6317) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA2446) |
| Enumeration Date | 2017-09-29 |
| Last Update Date | 2025-03-05 |