| NPI | 1790073252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 002219) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01533) |
| Enumeration Date | 2011-07-19 |
| Last Update Date | 2024-01-11 |