| NPI | 1588032106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2018019316) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 101576) |
| 363AS0400X Physician Assistant Surgical (Licence: MO 2018019316) | |
| Enumeration Date | 2015-09-14 |
| Last Update Date | 2024-05-09 |