| NPI | 1376883397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 5235-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA2286) |
| 363A00000X Physician Assistant (Licence: IN 10002329A) | |
| Enumeration Date | 2013-02-28 |
| Last Update Date | 2021-06-02 |