| NPI | 1972213148 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA2930) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 2961) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2022-11-29 |
| Last Update Date | 2025-09-03 |