| NPI | 1891306882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8066) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 2096) |
| Enumeration Date | 2020-08-12 |
| Last Update Date | 2023-12-21 |