| NPI | 1346732658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ME PA2255) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363A00000X Physician Assistant (Licence: ME PA2255) | |
| 363AS0400X Physician Assistant, Surgical (Licence: CA 55713) | |
| Enumeration Date | 2018-06-01 |
| Last Update Date | 2025-02-03 |