| NPI | 1649794991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4630-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 088418) |
| Enumeration Date | 2017-07-28 |
| Last Update Date | 2023-01-25 |