| NPI | 1619936572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 1845) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61458531) |
| Enumeration Date | 2006-03-20 |
| Last Update Date | 2024-05-31 |