| NPI | 1730364142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0030894) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VT 055-0030894) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9104082) | |
| Enumeration Date | 2008-01-03 |
| Last Update Date | 2024-07-15 |