| NPI | 1730690488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI 01170) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2855) |
| 363AM0700X Physician Assistant, Medical (Licence: RI PA01170) | |
| Enumeration Date | 2017-10-21 |
| Last Update Date | 2022-12-27 |