| NPI | 1124350806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031026) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VT 055-0031026) |
| Enumeration Date | 2010-02-05 |
| Last Update Date | 2025-11-07 |