| NPI | 1336891118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VT 055.0031808) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA063427) |
| 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00708300) | |
| 363A00000X Physician Assistant (Licence: VT 055.0031808) | |
| Enumeration Date | 2022-01-22 |
| Last Update Date | 2026-03-27 |