| NPI | 1912052853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 1575) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 0563P) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2014-05-20 |