| NPI | 1063478055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 2096) |
| Additional Taxonomies | 174400000X Specialist (Licence: GA 3618) |
| Enumeration Date | 2006-04-26 |
| Last Update Date | 2015-02-02 |