| NPI | 1275509853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0031105) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 007856) |
| Enumeration Date | 2006-02-24 |
| Last Update Date | 2016-04-13 |