| NPI | 1710356274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00905) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 746014) |
| Enumeration Date | 2015-09-15 |
| Last Update Date | 2025-12-10 |