| NPI | 1558561993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 022045) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 2119) |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601004947) | |
| Enumeration Date | 2007-07-24 |
| Last Update Date | 2019-08-23 |