| NPI | 1356725006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 5448) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5442) |
| Enumeration Date | 2015-07-13 |
| Last Update Date | 2021-08-04 |