| NPI | 1700485224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA 8084) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NH 1657) |
| Enumeration Date | 2020-10-26 |
| Last Update Date | 2023-08-09 |