| NPI | 1003261439 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031298) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1844) |
| Enumeration Date | 2016-05-04 |
| Last Update Date | 2022-04-09 |