| NPI | 1124066642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 0433P) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 0550030828) |
| 363AM0700X Physician Assistant, Medical (Licence: NH 0433P) | |
| Enumeration Date | 2006-06-04 |
| Last Update Date | 2018-07-02 |