| NPI | 1811916463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ME PA2870) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA2870) |
| 363A00000X Physician Assistant (Licence: MI 5601001593) | |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2025-08-12 |