| NPI | 1003512476 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA102140) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: RI PA01545) |
| Enumeration Date | 2023-02-06 |
| Last Update Date | 2025-11-20 |