| NPI | 1003326216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4937-23) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601008440) |
| Enumeration Date | 2017-10-03 |
| Last Update Date | 2022-11-15 |