| NPI | 1265777882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031397) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VT 040.0086261) |
| Enumeration Date | 2012-12-07 |
| Last Update Date | 2018-09-13 |