| NPI | 1487897104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0031687) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2967) |
| Enumeration Date | 2009-04-10 |
| Last Update Date | 2023-09-08 |