| NPI | 1740272616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA139) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 0655) |
| Enumeration Date | 2005-08-17 |
| Last Update Date | 2024-05-07 |