| NPI | 1225721848 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 14660) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-05-30 |
| Last Update Date | 2023-12-07 |