| NPI | 1104171537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 7743) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 20114) |
| 225100000X Physical Therapist (Licence: PA PT023343) | |
| 363A00000X Physician Assistant (Licence: RI PA01277) | |
| Enumeration Date | 2012-07-23 |
| Last Update Date | 2024-05-12 |