| NPI | 1639445646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031121) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 0909) |
| Enumeration Date | 2012-03-24 |
| Last Update Date | 2021-05-19 |