| NPI | 1295015667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00671) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1589) |
| 363A00000X Physician Assistant (Licence: UT 7875501-1206) | |
| 363A00000X Physician Assistant (Licence: IA 002194) | |
| Enumeration Date | 2011-08-17 |
| Last Update Date | 2013-03-18 |