| NPI | 1104117431 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4149) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00579) |
| Enumeration Date | 2011-04-20 |
| Last Update Date | 2015-11-11 |