| NPI | 1679568349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NC 0010-11814) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: VT 055-0030633) |
| Enumeration Date | 2005-09-19 |
| Last Update Date | 2024-03-12 |