| NPI | 1114165123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 0841) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA3722) |
| Enumeration Date | 2009-01-29 |
| Last Update Date | 2021-08-10 |