| NPI | 1104803170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA1791) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 021257) |
| 363A00000X Physician Assistant (Licence: RI PA01297) | |
| 363A00000X Physician Assistant (Licence: VA 0110002195) | |
| 363A00000X Physician Assistant (Licence: WV 2338) | |
| 363A00000X Physician Assistant (Licence: MA PA9410) | |
| 363A00000X Physician Assistant (Licence: CT 5102) | |
| Enumeration Date | 2005-12-29 |
| Last Update Date | 2024-07-24 |