| NPI | 1255511531 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 0703) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA AP2435) |
| Enumeration Date | 2007-11-05 |
| Last Update Date | 2017-01-10 |