| NPI | 1205087608 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA2093) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00562) |
| Enumeration Date | 2008-10-02 |
| Last Update Date | 2020-10-28 |