| NPI | 1134358104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1079) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VT 0550030979) |
| Enumeration Date | 2009-07-10 |
| Last Update Date | 2022-08-25 |