| NPI | 1710331095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00874) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5967) |
| Enumeration Date | 2016-04-22 |
| Last Update Date | 2018-12-07 |