| NPI | 1588308258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 7708-23) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA15731) |
| Enumeration Date | 2022-04-27 |
| Last Update Date | 2024-05-16 |