| NPI | 1902866841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME pa1122) |
| 363A00000X Physician Assistant (Licence: NY 020821) | |
| Enumeration Date | 2006-03-24 |
| Last Update Date | 2017-10-27 |