| NPI | 1639112758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ME PA001074) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 1882) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2012-08-02 |