| NPI | 1669836300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06360) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA2229) |
| Enumeration Date | 2016-04-08 |
| Last Update Date | 2021-07-16 |