| NPI | 1174083794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA8369) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: RI PA01112) |
| 363AS0400X Physician Assistant, Surgical (Licence: RI PA01112) | |
| Enumeration Date | 2019-03-20 |
| Last Update Date | 2026-01-16 |