| NPI | 1053405043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 2180) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00413) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2020-11-03 |