| NPI | 1093577017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031845) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2024-0042) |
| Enumeration Date | 2024-01-25 |
| Last Update Date | 2025-11-28 |