| NPI | 1992719132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0030893) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 0424747) |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2014-01-24 |