| NPI | 1548484090 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 1197) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: RI PA00602) | |
| Enumeration Date | 2007-04-13 |
| Last Update Date | 2024-09-25 |