| NPI | 1396151619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA1490) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 3133) |
| Enumeration Date | 2014-07-08 |
| Last Update Date | 2021-02-24 |