| NPI | 1104360650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 3895 - 23) |
| Additional Taxonomies | 133V00000X Dietitian, Registered (Licence: 1071971) |
| Enumeration Date | 2016-12-16 |
| Last Update Date | 2016-12-16 |