| NPI | 1184920928 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105689) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01449) |
| 363A00000X Physician Assistant (Licence: NH 1877) | |
| 363A00000X Physician Assistant (Licence: NY 028370) | |
| Enumeration Date | 2011-01-26 |
| Last Update Date | 2023-02-07 |