| NPI | 1285955666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11848) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ME PA 001213) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-02263) | |
| 363AS0400X Physician Assistant, Surgical (Licence: ME PA 001213) | |
| Enumeration Date | 2010-06-19 |
| Last Update Date | 2024-07-19 |