| NPI | 1184977514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00716) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 15285) |
| Enumeration Date | 2012-10-23 |
| Last Update Date | 2025-05-16 |