| NPI | 1629051446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 543) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 543-023) |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 543-023) | |
| Enumeration Date | 2005-11-25 |
| Last Update Date | 2020-12-15 |