| NPI | 1962492264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: MA RN154375) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA 494) |
| 363A00000X Physician Assistant (Licence: RI PA00055) | |
| Enumeration Date | 2005-10-27 |
| Last Update Date | 2016-11-30 |