| NPI | 1245395086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 34) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 1077) |
| 363AM0700X Physician Assistant, Medical (Licence: WI 028) | |
| Enumeration Date | 2006-12-22 |
| Last Update Date | 2012-06-07 |