| NPI | 1811446065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VT 055.0031381) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3837-023) |
| Enumeration Date | 2016-09-29 |
| Last Update Date | 2023-03-02 |