| NPI | 1205832045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 3020023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9102835) |
| Enumeration Date | 2005-06-27 |
| Last Update Date | 2023-03-07 |