| NPI | 1619208618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4602) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 0765) |
| Enumeration Date | 2010-01-15 |
| Last Update Date | 2021-01-13 |