| NPI | 1083790307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00780) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1058339) |
| Enumeration Date | 2006-10-29 |
| Last Update Date | 2022-03-29 |