| NPI | 1720466972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0031277) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1098) |
| Enumeration Date | 2015-05-08 |
| Last Update Date | 2015-12-30 |