| NPI | 1720124316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: ME PA1662) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA1662) |
| 363AM0700X Physician Assistant Medical (Licence: NY 010518) | |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2019-03-11 |