| NPI | 1386604569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 1745) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1234) |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2020-11-05 |