| NPI | 1629774591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WI 7267) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-02-02 |
| Last Update Date | 2023-03-30 |