| NPI | 1942413877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA2989) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA15865) |
| Enumeration Date | 2007-05-07 |
| Last Update Date | 2026-07-06 |