| NPI | 1104318427 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA101610) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01048) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2018-06-01 |
| Last Update Date | 2025-10-09 |