| NPI | 1497000434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4765) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI CPA00648) |
| Enumeration Date | 2012-07-16 |
| Last Update Date | 2014-03-03 |