| NPI | 1770771644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA1809) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10005252) |
| Enumeration Date | 2007-10-04 |
| Last Update Date | 2018-08-06 |