| NPI | 1265800023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI CPA00837) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA7807) |
| Enumeration Date | 2015-09-10 |
| Last Update Date | 2020-10-30 |