| NPI | 1518003474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI 363A00000X) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 3698) |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2022-12-20 |