| NPI | 1477190742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1594) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 055.0031457) |
| Enumeration Date | 2019-12-05 |
| Last Update Date | 2022-01-26 |