| NPI | 1922162387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 4245) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: RI PA00412) |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2014-12-08 |