| NPI | 1043617434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031321) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA09021) |
| Enumeration Date | 2014-12-01 |
| Last Update Date | 2020-04-22 |