| NPI | 1184670101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA633) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NH 0075P) |
| Enumeration Date | 2006-05-25 |
| Last Update Date | 2024-09-14 |