| NPI | 1417952896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 892) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 892) |
| 363AM0700X Physician Assistant, Medical (Licence: IA 001037) | |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2024-01-16 |