| NPI | 1043843592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 5116-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1164228) |
| Enumeration Date | 2020-02-12 |
| Last Update Date | 2022-03-01 |