| NPI | 1033143375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4960) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9921) |
| Enumeration Date | 2006-07-11 |
| Last Update Date | 2020-04-08 |