| NPI | 1760412084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00358) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA4234) |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2015-03-05 |