| NPI | 1619308178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 3006) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01045) |
| Enumeration Date | 2013-12-10 |
| Last Update Date | 2026-03-10 |