| NPI | 1730700220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA8291) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 3677) |
| Enumeration Date | 2020-05-06 |
| Last Update Date | 2026-05-14 |