| NPI | 1881051902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA01704) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2016-01-20 |
| Last Update Date | 2025-12-16 |