| NPI | 1306813563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WI 774) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 835) |
| Enumeration Date | 2006-03-07 |
| Last Update Date | 2021-12-15 |