| NPI | 1619937703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 0486P) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 0550030669) |
| Enumeration Date | 2006-03-24 |
| Last Update Date | 2008-04-22 |