| NPI | 1790763050 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 2956) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA-638) |
| Enumeration Date | 2006-01-06 |
| Last Update Date | 2021-10-20 |