| NPI | 1376878025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031257) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA3883) |
| Enumeration Date | 2009-10-14 |
| Last Update Date | 2015-10-01 |