| NPI | 1548296494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 767-23) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WI 767-023) |
| Enumeration Date | 2006-06-23 |
| Last Update Date | 2020-01-23 |