| NPI | 1962061663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NH 1644) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1644) |
| 363AM0700X Physician Assistant, Medical (Licence: VT 005.0031527) | |
| Enumeration Date | 2019-06-07 |
| Last Update Date | 2023-05-18 |