| NPI | 1194721118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 1803) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 9960) |
| Enumeration Date | 2005-06-23 |
| Last Update Date | 2009-06-05 |