| NPI | 1891143681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA1614) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5619) |
| Enumeration Date | 2016-06-02 |
| Last Update Date | 2018-08-15 |