| NPI | 1427163500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 20-023) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WI 60716-030) |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2008-05-02 |