| NPI | 1093364895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8061) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 055.0031434) |
| Enumeration Date | 2019-09-05 |
| Last Update Date | 2021-08-11 |