| NPI | 1538712583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4811) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 14898) |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 4811-23) | |
| Enumeration Date | 2019-07-18 |
| Last Update Date | 2024-07-10 |