| NPI | 1619325990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1167) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5723) |
| Enumeration Date | 2016-05-27 |
| Last Update Date | 2016-05-27 |