| NPI | 1407808272 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00302) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NY 008271-1) |
| Enumeration Date | 2006-05-17 |
| Last Update Date | 2007-07-08 |