| NPI | 1063492221 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2332) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 17747) |
| Enumeration Date | 2006-01-21 |
| Last Update Date | 2021-11-22 |