NPI | 1730364142 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VT 055-0030894) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9104082) |
Enumeration Date | 2008-01-03 |
Last Update Date | 2011-07-22 |