| NPI | 1942514120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA164524) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA2153) |
| Enumeration Date | 2010-07-30 |
| Last Update Date | 2022-02-03 |