| NPI | 1568870897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1713) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5505) |
| Enumeration Date | 2014-07-30 |
| Last Update Date | 2021-05-10 |