| NPI | 1083240865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WI 7724) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601009819) |
| 363A00000X Physician Assistant (Licence: IA 105631) | |
| Enumeration Date | 2020-03-12 |
| Last Update Date | 2024-01-08 |