| NPI | 1508950593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 1406-023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601003697) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2011-04-29 |