| NPI | 1164971610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA2629) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA MD60696527) |
| Enumeration Date | 2016-09-26 |
| Last Update Date | 2024-02-08 |