| NPI | 1134426133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4164) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00582) |
| Enumeration Date | 2011-02-28 |
| Last Update Date | 2011-04-13 |