| NPI | 1306189550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 7276) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 115288) |
| Enumeration Date | 2013-04-05 |
| Last Update Date | 2025-09-05 |