| NPI | 1053763284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA56705) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: RI PA00892) |
| 363AS0400X Physician Assistant, Surgical (Licence: RI PA00892) | |
| Enumeration Date | 2016-07-12 |
| Last Update Date | 2020-06-03 |