| NPI | 1548759731 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA7141) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1355) |
| Enumeration Date | 2018-05-03 |
| Last Update Date | 2023-11-17 |