| NPI | 1336504588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061533) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ME PA1578) |
| Enumeration Date | 2015-12-15 |
| Last Update Date | 2020-09-02 |