| NPI | 1215544168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA7803) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01713) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2020-09-24 |
| Last Update Date | 2024-08-20 |