| NPI | 1407950652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 1232023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-02927) |
| Enumeration Date | 2006-09-09 |
| Last Update Date | 2020-10-20 |