| NPI | 1174740518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0030833) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011564-1) |
| 363A00000X Physician Assistant (Licence: MA 1265) | |
| Enumeration Date | 2007-04-19 |
| Last Update Date | 2023-03-07 |