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 |