| NPI | 1194019935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VT 055.0031140) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 014738) |
| Enumeration Date | 2011-06-08 |
| Last Update Date | 2025-08-20 |