| NPI | 1982960696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: RI PA00645) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA4793) |
| Enumeration Date | 2012-04-06 |
| Last Update Date | 2022-01-24 |