| NPI | 1689609844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VT 055-0031079) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 6015963-1206) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2017-01-10 |