| NPI | 1497766711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VT 055-0030217) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NH 0209) |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2015-02-04 |