| NPI | 1831594134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5181) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: MA PA5181) |
| 363A00000X Physician Assistant (Licence: RI #PA 00788) | |
| Enumeration Date | 2014-10-29 |
| Last Update Date | 2021-10-15 |