| NPI | 1669907218 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA101947) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: RI PA00954) | |
| Enumeration Date | 2017-04-20 |
| Last Update Date | 2025-08-26 |