| NPI | 1972848463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 5359) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00688) |
| Enumeration Date | 2012-12-10 |
| Last Update Date | 2021-03-26 |