| NPI | 1790070654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA001280) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2011-06-17 |
| Last Update Date | 2014-08-12 |