| NPI | 1346760360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: ME PA2281) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CT 003903) |
| 363AS0400X Physician Assistant Surgical | |
| 363AS0400X Physician Assistant Surgical (Licence: CT 003903) | |
| 363A00000X Physician Assistant (Licence: CT 003903) | |
| Enumeration Date | 2017-06-21 |
| Last Update Date | 2022-02-02 |