| NPI | 1376383646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1221241) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA100777) |
| 363A00000X Physician Assistant (Licence: ME PA2734) | |
| Enumeration Date | 2024-05-25 |
| Last Update Date | 2024-09-09 |