| NPI | 1093707655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00417) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 102283) |
| Enumeration Date | 2005-08-19 |
| Last Update Date | 2010-10-22 |