| NPI | 1669602835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA3806) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00508) |
| 363AS0400X Physician Assistant Surgical (Licence: MA PA3806) | |
| Enumeration Date | 2009-07-21 |
| Last Update Date | 2016-11-07 |