| NPI | 1255729919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA5320) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ME PA1905) |
| Enumeration Date | 2015-01-05 |
| Last Update Date | 2025-09-24 |