| NPI | 1760793780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4036) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00556) |
| Enumeration Date | 2010-06-24 |
| Last Update Date | 2023-08-21 |