| NPI | 1528580966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: ME PA1241) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 055.0031348) |
| 363A00000X Physician Assistant | |
| 363A00000X Physician Assistant (Licence: ME PA1241) | |
| Enumeration Date | 2017-07-07 |
| Last Update Date | 2021-12-02 |