| NPI | 1255672465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4229-23) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA174762) |
| Enumeration Date | 2013-03-13 |
| Last Update Date | 2017-11-02 |