| NPI | 1760467971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 5181) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA 00254) |
| 363A00000X Physician Assistant (Licence: MA 1281) | |
| Enumeration Date | 2005-12-09 |
| Last Update Date | 2024-04-29 |