| NPI | 1588181523 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 117648) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4607) |
| Enumeration Date | 2017-08-29 |
| Last Update Date | 2023-05-16 |