| NPI | 1730231705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA1478) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00371) |
| Enumeration Date | 2007-01-18 |
| Last Update Date | 2020-11-05 |