| NPI | 1114499779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA01507) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 023160) |
| Enumeration Date | 2018-12-20 |
| Last Update Date | 2023-03-06 |