| NPI | 1407696917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA101399) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 3644) |
| Enumeration Date | 2024-05-31 |
| Last Update Date | 2026-03-29 |