| NPI | 1346753407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6310) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 055.0031868) |
| Enumeration Date | 2017-11-13 |
| Last Update Date | 2026-04-06 |