| NPI | 1255361853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2087) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2001032799) |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2021-03-18 |