| NPI | 1902079494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA PA4309) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA4309) |
| Enumeration Date | 2008-04-07 |
| Last Update Date | 2026-03-10 |