| NPI | 1437394095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0030949) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA3984) |
| Enumeration Date | 2008-12-11 |
| Last Update Date | 2021-06-10 |