| NPI | 1720821952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA2940) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 006861) |
| Enumeration Date | 2024-06-15 |
| Last Update Date | 2025-09-08 |