| NPI | 1629166210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA2477) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: OH 50001662) | |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2023-06-26 |