| NPI | 1710711767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA101991) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 2856) |
| 363AM0700X Physician Assistant, Medical (Licence: NH 2856) | |
| Enumeration Date | 2024-08-30 |
| Last Update Date | 2025-08-29 |