| NPI | 1598963019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110009634) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 2121-023) |
| 363A00000X Physician Assistant (Licence: OH 50.005103RX) | |
| 363A00000X Physician Assistant (Licence: KY PA2250) | |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 2121-23) | |
| Enumeration Date | 2007-07-05 |
| Last Update Date | 2024-04-05 |