| NPI | 1780152728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01165) |
| Enumeration Date | 2018-11-07 |
| Last Update Date | 2022-05-12 |