| NPI | 1164700613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA5527) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 19241) |
| Enumeration Date | 2011-08-02 |
| Last Update Date | 2023-04-03 |