| NPI | 1013380138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 5381-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 079619) |
| 363A00000X Physician Assistant (Licence: MN 12647) | |
| Enumeration Date | 2015-11-11 |
| Last Update Date | 2022-03-24 |