| NPI | 1861606220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA101824) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1417) |
| Enumeration Date | 2007-05-09 |
| Last Update Date | 2026-01-05 |