| NPI | 1851698260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA01378) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA 4169) |
| 363A00000X Physician Assistant (Licence: VT 055-0031089) | |
| Enumeration Date | 2011-02-21 |
| Last Update Date | 2022-07-13 |