| NPI | 1588990790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02084) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00703) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-02084) | |
| Enumeration Date | 2009-10-22 |
| Last Update Date | 2021-08-07 |