| NPI | 1164056727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 5119-23) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363AM0700X Physician Assistant, Medical (Licence: WI 5119-23) | |
| Enumeration Date | 2020-02-23 |
| Last Update Date | 2020-09-02 |