| NPI | 1790734861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ME PA1405) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 2169-1) |
| Enumeration Date | 2006-05-08 |
| Last Update Date | 2013-06-26 |