| NPI | 1548321904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 2227) |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2021-08-04 |