| NPI | 1770681587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VT 055.0031007) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NY 0011155) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2019-06-11 |