| NPI | 1316976814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 1850-023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA15815) |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 1850-023) | |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2022-09-06 |