| NPI | 1851025357 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA9586) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01631) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2022-07-12 |
| Last Update Date | 2024-12-12 |