| NPI | 1700438546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031517) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-09059) |
| Enumeration Date | 2019-07-11 |
| Last Update Date | 2021-08-11 |