| NPI | 1720376569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105521) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA001216) |
| Enumeration Date | 2011-07-14 |
| Last Update Date | 2011-07-14 |