| NPI | 1780681536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA1496) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00283) |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2023-11-17 |