| NPI | 1295926681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 0550031115) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM pa20090038) |
| Enumeration Date | 2007-08-09 |
| Last Update Date | 2012-03-12 |