| NPI | 1629554811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA2345) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR 189176) |
| Enumeration Date | 2018-07-11 |
| Last Update Date | 2023-01-05 |