| NPI | 1740782671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6507) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01128) |
| Enumeration Date | 2018-03-07 |
| Last Update Date | 2024-06-06 |