| NPI | 1891785671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VT 055-0030786) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: VT 055-0030786) |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2013-11-12 |