| NPI | 1073570016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4175) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00787) |
| Enumeration Date | 2006-04-26 |
| Last Update Date | 2020-08-14 |