| NPI | 1750856647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055.0031458) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 10516) |
| Enumeration Date | 2018-10-08 |
| Last Update Date | 2024-10-23 |