| NPI | 1891034559 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA1695) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA4614) |
| Enumeration Date | 2013-01-31 |
| Last Update Date | 2020-10-01 |