| NPI | 1386231645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA2594) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601010225) |
| Enumeration Date | 2020-12-21 |
| Last Update Date | 2024-02-29 |