| NPI | 1023013364 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 507) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 8874) |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2023-02-08 |