| NPI | 1275838146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2904-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2011001605) |
| Enumeration Date | 2011-01-24 |
| Last Update Date | 2021-04-23 |