| NPI | 1629385893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 3323) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 002144) |
| Enumeration Date | 2010-09-08 |
| Last Update Date | 2023-10-15 |