| NPI | 1467456848 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 950) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 950) |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 950) | |
| 363AS0400X Physician Assistant, Surgical (Licence: MO 2005034534) | |
| Enumeration Date | 2005-06-13 |
| Last Update Date | 2024-07-24 |