| NPI | 1811910904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA1691) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 055-0030663) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2019-06-05 |