| NPI | 1487668687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: ME PA1659) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601002629) |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2017-01-24 |