| NPI | 1184192684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 0.55.0031555) |
| Enumeration Date | 2018-11-02 |
| Last Update Date | 2024-02-16 |