| NPI | 1114582541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4749) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10003391A) |
| 363A00000X Physician Assistant (Licence: IL 085008285) | |
| Enumeration Date | 2019-05-01 |
| Last Update Date | 2024-02-21 |