| NPI | 1669949335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1458) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA101346) |
| Enumeration Date | 2018-10-30 |
| Last Update Date | 2025-02-05 |