| NPI | 1659314961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA 1952) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NH 1697) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2021-04-28 |