| NPI | 1609822543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 275-23) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 275-023) |
| Enumeration Date | 2006-05-25 |
| Last Update Date | 2020-12-15 |