| NPI | 1104386895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA01114) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA7012) |
| Enumeration Date | 2019-03-20 |
| Last Update Date | 2020-09-11 |