| NPI | 1104851633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0031054) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101620) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2013-08-22 |