| NPI | 1487640165 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031225) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 010315-1) |
| Enumeration Date | 2005-09-27 |
| Last Update Date | 2023-10-27 |