| NPI | 1962488213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA1459) |
| Additional Taxonomies | 364S00000X Clinical Nurse Specialist (Licence: CT 000107) |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2014-08-05 |