| NPI | 1215627575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 7440-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601011806) |
| Enumeration Date | 2023-05-10 |
| Last Update Date | 2023-08-31 |