| NPI | 1508126681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031197) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NH 0895) |
| Enumeration Date | 2012-05-22 |
| Last Update Date | 2015-06-26 |