| NPI | 1801863337 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00297) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 1591) |
| 363A00000X Physician Assistant (Licence: CT 002523) | |
| Enumeration Date | 2006-03-03 |
| Last Update Date | 2013-10-08 |