| NPI | 1992367734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA7841) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01161) |
| Enumeration Date | 2019-07-02 |
| Last Update Date | 2021-04-21 |