| NPI | 1407110653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 7534) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 100887-875) |
| Enumeration Date | 2012-07-02 |
| Last Update Date | 2023-08-28 |