| NPI | 1174592059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 1692) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA AP2099) |
| 363A00000X Physician Assistant (Licence: RI PA00387) | |
| 363AM0700X Physician Assistant, Medical (Licence: MA AP2099) | |
| 363AM0700X Physician Assistant, Medical (Licence: RI PA00387) | |
| 363AS0400X Physician Assistant, Surgical (Licence: MA AP2099) | |
| 363AS0400X Physician Assistant, Surgical (Licence: RI PA00387) | |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2015-08-05 |