| NPI | 1063408417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 8502-23) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IL 085-002220) |
| Enumeration Date | 2005-09-21 |
| Last Update Date | 2025-08-22 |