| NPI | 1588856066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ME163639) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CA PA19300) |
| Enumeration Date | 2007-08-17 |
| Last Update Date | 2023-08-01 |