| NPI | 1629300124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4313) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NH 0758) |
| Enumeration Date | 2010-02-08 |
| Last Update Date | 2012-01-11 |