| NPI | 1184082893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 5689) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-005221) |
| Enumeration Date | 2016-02-09 |
| Last Update Date | 2022-02-08 |