| NPI | 1790797116 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VT 055-0031268) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001695) |
| Enumeration Date | 2006-08-13 |
| Last Update Date | 2015-10-05 |