| NPI | 1861232373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA102031) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 3543) |
| Enumeration Date | 2024-05-31 |
| Last Update Date | 2025-10-14 |