| NPI | 1952700841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0031310) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2014-08-18 |
| Last Update Date | 2023-08-09 |