| NPI | 1629436548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00927) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CT 23.003522) |
| Enumeration Date | 2016-02-06 |
| Last Update Date | 2023-03-21 |