| NPI | 1710362421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA1677) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 018645) |
| Enumeration Date | 2015-07-23 |
| Last Update Date | 2017-05-12 |