| NPI | 1336566421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008479) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA1492) |
| Enumeration Date | 2014-03-26 |
| Last Update Date | 2022-07-21 |