| NPI | 1245252030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 5530304) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 004999) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2016-02-22 |