| NPI | 1821492323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 57632) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA1551) |
| 363AS0400X Physician Assistant, Surgical (Licence: MD C0005588) | |
| Enumeration Date | 2014-10-14 |
| Last Update Date | 2023-06-29 |