| NPI | 1629473293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8709) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 52101) |
| 363A00000X Physician Assistant (Licence: NH 1340) | |
| Enumeration Date | 2014-10-24 |
| Last Update Date | 2023-12-05 |