| NPI | 1457010696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 5749) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 5749) |
| Enumeration Date | 2021-12-15 |
| Last Update Date | 2024-01-05 |