| NPI | 1730616806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1499) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4080-23) |
| Enumeration Date | 2017-05-18 |
| Last Update Date | 2019-10-31 |