| NPI | 1720727019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031668) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2022-06-03 |
| Last Update Date | 2023-04-20 |