| NPI | 1104150374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA3833) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00524) |
| Enumeration Date | 2009-09-22 |
| Last Update Date | 2023-11-17 |