| NPI | 1306345244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6451) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1375) |
| Enumeration Date | 2018-02-06 |
| Last Update Date | 2024-07-22 |