| NPI | 1083611073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA01738) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 000866) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 000866) | |
| Enumeration Date | 2005-07-05 |
| Last Update Date | 2025-04-09 |