| NPI | 1295105476 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6280) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00840) |
| Enumeration Date | 2015-10-01 |
| Last Update Date | 2018-09-14 |