| NPI | 1225061906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9653) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 1988) |
| 363A00000X Physician Assistant (Licence: CO PA.0004932) | |
| Enumeration Date | 2006-07-08 |
| Last Update Date | 2020-05-04 |